between alcoholic dementia and cerebral tumor, and here from our records the diagnosis would seem to be arteriosclerosis.

Three cases were called manic-depressive. Of these, one is clearly, from our records, a case of arteriosclerotic dementia and she has apparently an early stage of chorea. Had the chorea come on somewhat earlier in the course and been more marked, we should have been tempted to call her a case of "degenerative chorea." There are no evident signs of manic-depressive. To be sure she has periods of depression and excitement, never long continued, amounting really to an emotional instability. In the other two cases the portion of the symptomatology which is unusual for manic-depressive lies in the periods of confusions. Aside from this, one case might well be regarded as a manicdepressive-mixed and the other as a manic-depressive-depressed.

Group IX.-Korsakow's: This syndrome is one which has very definite signs and one in which we should not expect the diagnosis to be in error. However, there were four cases in which we seem to have made an erroneous diagnosis. One of these was called alcoholic dementia. It is well known that the outcome of a Korsakow's attack is often dementia and this dementia is usually very marked. Accordingly, in this case we are probably both right in the diagnosis. A second case recovered from a "toxic psychosis," which, of course, Korsakow's syndrome is. A third case was discharged as recovered from alcoholic hallucinosis. There were here certain slight signs of neuritis and some confusion which allowed us to believe that it was an early phase of Korsakow's. Apparently, however, the damage was not so great and the case ran the course of an hallucinosis. The fourth case was a very interesting one in which we were none too sure of the diagnosis, "Korsakow's," but we were unable, after an exhaustive study for more than a month, to reach any other conclusion. He has been left "unclassified" and is improving.

Group X.-The paranoid conditions constitute one of the most difficult groups in which to make a differential diagnosis. The tendency has been to classify the hallucinated paranoid conditions as paranoid dementia præcox, reserving the term "paranoia" for those cases of very long and slow evolution, in which there is a

well-systematized set of paranoid ideas without hallucinations and without deterioration. We made the diagnosis of paranoid in only two cases. In each case the state institutions made a diagnosis of paranoid dementia præcox, which I believe to be correct in one and probably incorrect in the other.

According to Kraepelin's last edition only about 40 per cent of the paranoid conditions with progressive delusion formation, not due to syphilis or alcohol, are cases of dementia præcox. The deterioration is often very slow in developing in these cases. About 50 to 55 per cent of the paranoid group as limited are cases of paraphrenia, while the remaining small percentage are cases of true paranoia.

We attempt now to differentiate the paranoid præcox group from the other paranoid cases by insisting that they show the characteristic emotion and will difficulties of schizophrenia. If they do not show these signs we usually leave them in the unclassified paranoid group. In one case we made a diagnosis of paraphrenia confabulans, which was changed to dementia præcox paranoid. This and two other changes from unclassified paranoid to dementia præcox represent really differences in standards of diagnosis and not any particular differences in the conception of the case. The final case, however, was a very interesting legal case in which we were not able certainly to determine the presence of hallucinations or to show any very marked deterioration. We felt that she was probably a paranoid præcox, but thought it safer to leave the case unclassified paranoid. Since being at the other hospital she has shown very clearly the characteristics of paranoid dementia præcox.

Group XI-Unclassified: Concerning this group I have very little to say. They represent the cases in which for one reason or another we were not able definitely to decide what the psychosis was, during the period of observation here. They present, of course, a good many problems, as do all unclassified cases. In 18 of the 23 the other institutions were able to classify them but the institutions added, to the residue of five, eight more cases which they could not classify.

The remaining changes in diagnosis need not be discussed at very great length. They represent for the most part differences

in standards of diagnoses. Under the "not psychotic group" are included cases of feeble-mindedness and of psychopathic personality, which had for one reason or another to be committed. They all have a mental disease although it is not perhaps in the form of a psychosis. The scattering of further changes is not particularly important.

SUMMARY.

Data are presented dealing with the accuracy of the Psychopathic Hospital diagnoses on 419 patients. The Psychopathic diagnosis was determined within 10 days in all but a few. In a few cases we had more time, up to a month, to study the case. The cases have been followed for a year to a year and a half.

The figures are based upon the diagnoses made at II state institutions, McLean Hospital, and a small group of private sanitaria, to which our patients were committed. Most cases have been reported twice, and in a few instances three times.

The general error in diagnosis is established at 23.0 per cent (omitting the unclassified cases from consideration).

This error is not evenly distributed. Our greatest accuracy is in epilepsy (100 per cent); next in neurosyphilis (92.3 per cent); then dementia præcox (85.2 per cent.) Of the larger groups we are least accurate in arteriosclerotic psychosis (54.5 per cent); then in Korsakow's (63.6 per cent); then the acute alcoholic psychoses (66.6 per cent); then manic-depressive and chronic alcohol psychoses (70 per cent).

Many cases have had more than one diagnosis from the other institutions.

We diagnosed dementia præcox in 183 cases: diagnosis changed in 28, of which four were left unclassified. Twenty-eight cases were added to this group.

Of the 24 definite changes, two were unclassified paranoid. In three cases our record seems clearly that of a manic-depressive; in one, manic-depressive + some unusual symptoms. In these four cases there should have been no error. One case of late katatonia should probably not be called manic-depressive. In three cases, our record is that of dementia præcox, and the outcome is not yet certain. In four cases our diagnosis seems symp

tomatically correct, but not verified by outcome. In three cases I believe neither diagnosis to be correct, and in four more I am fairly certain the final diagnosis is incorrect, but have no exact opinion as to correct diagnosis. In another case the accuracy of the history must decide: in two, I can form no opinion.

The diagnosis was changed in 18 of 60 cases called manicdepressive at the Psychopathic, and 21 cases were added. One case is left unclassed.

Of the 17 definite changes, my own opinion is as follows: That in eight cases, according to symptomatology and outcome, the Psychopathic diagnosis is probably correct; in four cases the Psychopathic record is such that a diagnosis of manic-depressive should not have been made, and the other institution is correct; in three, the second diagnosis is probably correct, although the Psychopathic diagnosis may eventually be proven.

Of the three errors made in the diagnosis of 39 cases of neurosyphilis, two should not have been made, since our record clearly agrees with the other institution's diagnosis. In the third case we recognized the presence of neurosyphilis, which the other institution did not.

Of the four errors in the diagnosis of 12 cases of the acute alcoholic group, I should doubt the " recovered" dementia præcox; believe that acute alcoholic hallucinosis is a better diagnosis than "toxic insanity"; and believe that a recovered manic-depressive showing "blunting due to the use of alcohol" probably had an alcoholic psychosis.

Two of the three errors in the chronic alcoholic group are really not errors, since we did not regard them as sufficiently deteriorated to commit as insane. The other case is a frank error.

In the arteriosclerotic group, changes to senile dementia occur three times. Such changes depend largely upon interpretation of findings. In four of the 10 cases in which diagnosis was changed, the second diagnosis seems to be erroneous, and in two more the diagnosis is less exact than ours, while one case is left unclassified.

The four changes in the diagnosis of Korsakow's syndrome represent: 1, A very difficult case in which we were none too sure of the diagnosis; 2, an end state (dementia); 3, a "toxic" psychosis; 4, alcoholic hallucinosis.

The paranoid conditions are often very difficult of exact diagnosis. Four of the six changes represent differences in diagnostic ideas; one more was caused by further developments in the course of the disease.

Therefore, in 396 cases diagnosticated, there were 91 changes. Of these nine are left unclassed, and the Psychopathic diagnosis may eventually be proven correct. Of the remaining 82, 10 are cases in which, from the Psychopathic record, no error should have been made. In 21 more the Psychopathic diagnosis is probably correct. Three cases classed as errors are not really so. In three cases probably neither diagnosis is correct. So, if we exclude the cases left unclassed; the cases in which we are probably correct and those in which there was really no error, we are left with a total of 58 frank errors among 396 cases, or 14.6 per cent. This raises the question: "What is the error in psychiatric diagnosis at large?" which can only be answered by each institution critically analyzing its own diagnoses and errors. Compilation of such figures from several institutions would be of extreme value.

It appears more and more strongly that accurate observation and intelligent interpretation are the fudamentals of correct diagnosis, and that there is need of a unification of diagnostic standards.

LITERATURE CITED.

1. Barrett, A. M.: Syphilitic Psychoses Associated with Manic-Depressive Symptoms and Course. J. A. M. A., LXVIII, December, 1916, p. 1639.

2. Lowrey, L. G.: An Analysis of the Accuracy of Early Psychiatric Diagnosis. Medicine and Surgery, Vol. II, 1918, p. 281.

3. Lowrey, L. G.: Differential Diagnosis in Psychiatry. Boston Medical and Surgical Journal, CLXXVIII, May, 1918, p. 703.

4 Lowrey, L. G.: Some Observations on the Relationship between Syphilis of the Nervous System and the Psychoses. Am. Journal Insanity, LXXIV, July, 1917, p. 25.

5. Lowrey, L. G.: A Study of 58 Cases Diagnosed as Paresis in PreWassermann Days. Journal Nervous and Mental Dis., XLIII, 1916, p. 324.

6. Lowrey, L. G., and Smith, C. E.: Degenerative Chorea (Huntington Type) with the Serology of Paresis. Am. Jr. Syphilis, July, 1918. 7. Lowrey, L. G.: The Insane Psychoneurotic. Amer. Journ. Insan., 1918.